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Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
Odet Sarabia González M.D.
Advisor to the Vice Ministry of Quality and Innovation
Ministry of Health MexicoAugust 22nd 2007.
SIXTH ANNUAL QUALITY SIXTH ANNUAL QUALITY COLLOQUIUM AT HARVARD COLLOQUIUM AT HARVARD
PATIENT SAFETY PATIENT SAFETY
LESSONS FROM MEXICOLESSONS FROM MEXICO
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
MEXICAN HEALTH SYSTEM
Private + Public
Government Provider
4000 Hospitals
3000 Public= 75% beds
1000 Private= 25% beds
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
WHAT DO WE WANT TO CHANGE?WHAT DO WE WANT TO CHANGE?
It seldom happens at
my hospital
Guiltiness
Finger-pointing
We are infallible
1. Not showing concerns.1. Not showing concerns.2. Not reporting incidents.2. Not reporting incidents.3. Not studying and 3. Not studying and
therefore, not knowing therefore, not knowing our reality.our reality.
4. Not taking measures for 4. Not taking measures for improvement.improvement.
Continue Continue harming harming the the patient.patient.
Lack of budget
Attitude
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
PATIENT SAFETYPATIENT SAFETY
• Internationally bursting movement that questions
about the kind of healthcare we provide.
• Involves all actors within the healthcare system.
• Regarded as a potentially severe and preventable
problem, with huge economic and social impact.
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
• National Crusade for Quality in Health Care
• Patient Safety Crisis Management Manual
• Pilot Sensitization Workshop-Course in Morelos
• Sensitization workshop course
• Logotype
• 10 Actions on patient safety
• Knowledge spreading: tri-monthly patient safety bulletins
• Patient safety indicators
• National Sentinel Event Reporting and Learning System
• Research Protocols
• Inclusion in the National Healthcare Program
2001
2003
2005
2007
New government
ACTIONS ON PATIENT SAFETYACTIONS ON PATIENT SAFETY
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
EIGHT STEPS FOR THE ORGANIZATIONAL CHANGE
1. Instill the sense of urge.
2. Create an oriented coalition.
3. Develop a vision and a strategy.
4. Communicate the vision of change.
5. Empower for action a wide base.
6. Generate quick triumphs.
7. Consolidate the gains and generate more changes.
8. Implant the new approaches on the culture.John P. Kotter
WORKSHOP ESTRUCTUREWORKSHOP ESTRUCTURE
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
MORELOS PILOT STUDY
• Global rating of the patient safety climate 62.61 (SD 21.01, CI 3.57 – 92.85) to 71.89 (SD 21.14, CI 10.71-100) (p = 0.01).
• Individuals with a satisfactory perception of the patient safety climate increased from 37.5 to 60.66% (p = 0.01).
55
60
65
70
75
Sco
re
Phase
Improvement in Patient Safety Climate
Phase 1Phase 2
0
20
40
60
80
Perc
enta
ge
Phase
Improvement in Satisfactory Patient Safety Climate
Phase 1Phase 2
62.61% to 71.89%
37.50% to 60.66%
ACTION LINESACTION LINES
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
WORKSHOP-COURSE ON PATIENT SAFETY
• 32 COUNTRY STATES
• ISSSTE. (Government employees).
• SEDENA. (Defense Secretary).
• MARINA.(Navy).
• PEMEX. (Oil Agency).
• 2 Federal Reference Hospitals.
• 1 National Institute.
SIC 46 hospitals / 565 attendance
TT 207 (Train the Trainers)
Cascade reproduction 189 hospitals
20,070 total attendance
WORKSHOP-COURSE ON PATIENT SAFETYEXTENDED TO 32 STATES AND PUBLIC
HEALTH SECTOR
ACTION LINESACTION LINES
2004
2006
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
2005
ACTION LINESACTION LINES
Triangular shaped:
International warning sign
Co responsibility between
Healthcare Institutions, Medical Staff and Patient
Patient
Medical Staff
Safety pin
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
2005
ACTION LINESACTION LINES
*Based on the Joint Commission Patient Safety Goals
*
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
http://innovacionycalidad.salud.gob.mx/10pasos.php
2005
2007
ACTION LINESACTION LINES
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
ACTION LINESACTION LINES
• Reports until July 24th 2007: 875
• States : 11
• Exponential reporting (Last month 150
reports)
2005
2007
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
ACTION LINESACTION LINES
Adverse Events Comparison Between HospitalsHospital
AHospital
B
% %
Shift where the adverse events occurred
Morning 75.30% 58.15%
Afternoon 12.05% 23.67%
Others 12.65% 17.88%
Services where the AE took place
ICU 24.70% 16.27%
ER 7.83% 40.36%
Surgery 22.89% 12.65%
Internal Medicine 10.84% 20.48%
Others 33.74% 10.24%
Sort of Adverse Event
In hospital infections 57.83% 4.83%
Sentinel Events 16.27% 43.96%
Others 25.90% 51.21%
SinRAECe-Example:Follow up
Two Years at Two General Hospitals
2004
2006
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
Adverse Event Comparison Between HospitalsHospit
al AHospit
al B
% Adverse events causing lengthening of hospital stay 63.86%
28.02%
Average of additional days In hospital stay9.19% 4.33%
% Adverse events experienced at working age (18 to 65 ) 74.10%
64.25%
% Patients or relatives not informed that an adverse event took place
87.95%
71.98%
Sentinel Events-Medication Errors 13.86%
20.09%
% Cases where the hospital took measures to prevent the adverse event from happening again
48.80%
97.10%
SinRAECe-Example:Follow up
Two Years at Two General Hospitals
ACTION LINESACTION LINES
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
2006
•Study with the CONAMED (Medical Arbitration Commission)
•Align actions with the CSG (General Health Council)
•Reinforce accreditation focusing on Patient Safety
•Prevalence study of adverse events at two general hospitals
2007
Inclusion in the National Health Program 2007-2012
ACTION LINESACTION LINES
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
World Alliance for Patient Safety, WHO,
Health and Consumption Ministry of Spain
• Measurement study of the prevalence of
adverse events in five countries of the Middle
and South America Region.
• Get to know the problem’s magnitude.
• Sensitization about the problem with hard data.
1. Argentina
2. Colombia
3. Costa Rica
4. México
5. Perú
IBEAS STUDY
2007
INTERNATIONAL ACTION LINESINTERNATIONAL ACTION LINES
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
2006
2007
•Start of the IBEAS study at 6 hospitals
•IBEAS study extended to:
1 hospital per State (previously trained on patient safety)
INTERNATIONAL ACTION LINESINTERNATIONAL ACTION LINES
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
WHO World Alliance for Patient Safety in America
First World Challenge “Clean Care is Safer Care”
Signing of the statement between Health Ministry and WHO
Canada (October 2006)
USA (November 2006)
Costa Rica (March 2007)
México (September 2007)
2 Regional signatures:
México (Mexico and Central America)
Uruguay (South America)
INTERNATIONAL ACTION LINESINTERNATIONAL ACTION LINES
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
1. The commitment should be from the highest hierarchy down to the patient himself.
2. To sensitize the healthcare personnel of all levels is a priority.
3. Basic education and training in patient safety must be started over periodically.
4. Team training (CEO´s, management team) has demonstrated better results than isolated individuals.
LESSONS LEARNTLESSONS LEARNT
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
5. Even when actions that lead to patient safety initially imply additional workload (change of procedures, verification of routines, learning), once the people has realized that benefits of the “safety attitude” are real, they become enthusiast promoters of the subject themselves.
6. A project that involves cultural change like patient safety, sooner or later delivers positive results when the seed has been sowed widely among the healthcare providers.
7. Successful Hospitals are those who have given continuity to training, for instance, facing staff’s rotation they have to be trained before assuming their new posts (even the director).
LESSONS LEARNTLESSONS LEARNT
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
8. The communication line must be clear, functional and well established, from the responsible of the patient safety program at the national level down to the operative levels of each hospital unit.
9. No matter where we are, or who are we talking to, our enthusiasm and conviction must always be evident, even when discussing the hardships of the project or recognizing the difficulties of a particular task.
LESSONS LEARNTLESSONS LEARNT
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
LESSONS LEARNTLESSONS LEARNT
10. Resources are greatly needed, not so much in the form of expensive, state of the art equipment and gizmos, but rather in preventive maintenance, basic structure, education and continuous support for training, policy making and promotion campaigns.
11. There ought to be a well planned and labeled budget for Patient Safety.
12. The structure that supports the Patient Safety Strategy has to be rational according to the expected outcomes.
13. It is desirable to count with a patient safety office on each and every hospital unit.
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
LESSONS LEARNTLESSONS LEARNT
14. Authorities ought to be extra careful assigning responsibilities and leading posts.
15. Healthcare providers should speak out when they have concerns regarding Patient safety and listen when their peers have them as well.
16. Involving medical, nursing students and residents, has been of great help, since they possess great enthusiasm and are the system’s future.
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
LESSONS LEARNTLESSONS LEARNT
17. A non punitive adverse event reporting system is necessity if we are to learn from the errors within our healthcare institutions. Even when the flow of reports might be slow at first, one has to patiently wait in order to gain trust and confidence from healthcare professionals.
18. The outcome of the waiting time (maturation process), is always a flow of precious data that enables the healthcare system to know how to deal with bad habits or get rid of the institution’s flaws that have been unnoticed for long.
19. Improvement efforts should focus on fixing the system’s failures, not in blaming healthcare providers.
20. All of us have a responsibility within the system where we work at.
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
A CHAIN IS JUST AS STRONG AS ITS WEAKEST A CHAIN IS JUST AS STRONG AS ITS WEAKEST
LINKLINK
Odet Sarabia González MD. Advisor to the Vice Ministry of Quality and Innovation.
THANK YOUTHANK YOU